July 1st, 2022


July 1, 2022

Letter to a Young Female Physician, Notes from a Medical Life by Suzanne Koven, M.D. (New York:  W.W. NORTON & COMPANY, 2021)

ISBN 9781324007142

Letter to a Young Female Physician, Notes from a Medical Life is a collection of essays by Suzanne Koven, M.D., doctor-colleague-writer-teacher-mother-daughter-sibling.*  Koven published the title piece in 2017 in the New England Journal of Medicine (“NEJM”), and she links this with a series of 24 informative, thought-provoking essays on the medical profession, physician-patient relationships, medical education, family and literature.  Many of the essays in this collection were previously published in outlets such as the NEJM, the Boston Globe, and Lancet.  (*I will explain this excessively-hyphenated adjective below).

In the collection’s titular piece, Koven addresses “imposter syndrome,” which describes the feeling of ‘being a fraud’ that a female medical student, intern, resident, fellow, or physician may experience.  As Koven points out in her Epilogue, entitled “Women in STEM,” feelings of imposterism in the medical profession are not limited to female physicians – indeed, after the piece was published, she received messages from, “not only young female physicians but also from men, older doctors, and readers who didn’t work in healthcare . . . Many women of color told me that they viewed imposter syndrome as internalized racism and sexism.”  The reality is that the medical professionals face many of the daunting feelings of inadequacy as experienced by other professionals and, indeed, as many experience in the workplace at large.  Interestingly, Koven notes that “imposter syndrome” was first described only in 1978, when Suzanne Imes and Pauline Chance, two psychologists at Georgia State University, defined the syndrome as “an internal experience of intellectual phoniness that appears to be particularly prevalent and intense among a select sample of high-achieving women.”

Yes, There Is a Doctor in the House.

Koven’s father was a doctor in New York and her mother, who features prominently in many of the essays, was both lawyer and homemaker (who, interestingly, went to law school at age 43).  Koven notes that her brothers and her, like their mother and father, were all born in the Brooklyn Jewish Hospital.  And her father eventually performed surgeries there.  Talk about a full circle:  having the honor of performing surgeries — saving or enhancing lives — in the same hospital where you were born!

Soft Skills and the Art of Medicine

In reading this book, both as an occasional patient of doctors but also in the practice of law, I truly appreciated Koven’s respect for “soft skills” or “the art of medicine.”  As with medicine, there is a science to the law but also the art.  Some lawyers and observers of the profession view lawyers primarily as those who file lawsuits and take cases to trial.  And, true, that can be part of practicing law.  But there are plenty of lawyers who rarely go to court and who help clients in other ways, through negotiations, counseling and planning activities that are designed to avoid going to court.  These lawyers, who don’t try cases in court, can suffer from imposter syndrome.

In discussing the art of medicine, Koven explains:

“Physicians and nurses now routinely team up with mental-health professionals, alternative practitioners, social workers, and chaplains to offer holistic care.  I participate in such teams and value them, but I’m not sure that even holistic medicine fully acknowledges the difficult-to-measure therapeutic effects of empathy, attentiveness, humor, intuitive reasoning, the ability to inspire hope, and other qualities sometimes called ‘soft skills’ (or, more appreciatively, ‘the art of medicine’) and which are as useful in my practice as antibiotics and MRIs, if not more so.”

Where the art and science merge is where we find many of the most effective and accomplished of practitioners.

The Author’s Embrace of Literature

A fascinating aspect of Koven’s life story is her obtaining a degree in Literature at the Harvard Extension school, completed over the course of 8 years.  Upon receiving her degree, Koven failed to inform her husband of her commencement until it was too late for him to miss work to attend, and, hence, her daughter attended as her ‘plus 1.’  In a revealing moment, Koven explains that her failure to timely inform her husband of the date, was perhaps a result of her fear that her husband would have advised that her literary studies – which were hardly dabbling, as Koven won an award, receiving A’s in every course – were somehow misleading, that she was faking her way along in the sideline of literature; that her literary passions were genuinely emblematic of her true self.  Yet her fear was misplaced.  She reveals, “My graduation, and other incidents like it, when I shut my husband out because I couldn’t bear to be seen and possibly be found deficient, are the greatest regrets of my life.”

Despite trepidation along the way, Koven’s career ultimately blossomed into a life’s work that incorporates literature and humanities in the medical profession.  She has been for years the Writer in Residence at Massachusetts General Hospital.  Koven, who can be her own harshest critic, feels that she started off slowly in guiding discussions of literature.  She was stilted at the outset and thought that the texts for study must be limited to works expressly addressing the medical profession.  Later, when she allowed her story-teller inclinations to shine, she grew into the role and became much better at it; in the process, she decides that humanities writing which can be useful to healthcare practitioners does not need to be related to the profession per se.  Rather, Koven realized that Shakespeare may have as much to say about the medical profession as do authors who set their works in the healthcare field:

“Over the next few years [  ], I found my bearings.  I unabashedly assigned nonmedical readings, Shakespear and Kafka and Yeats.  Tony Morrison and James Baldwin and Kazuo Ishiguro and David Sedaris and Alice Munro. . . .  [Eventually,] the doctors and nurses and the administrators talked.  On survey after survey they reported that reading and discussing works of literature had made them feel less stressed, more connected to their patients and to one another.”

Koven explains that, “Narrative medicine, the term coined in 2000 by Rita Charon at Columbia, is based on the idea that by studying literature closely, improving out skills in identifying tone, subtle shifts of mood, themes, and recurring metaphors, we become better at diagnosing and treating our patients. . . . [and m]ost important, Charon emphasizes how therapeutic it is for patients to be given permission to tell their stories in the manner and, most especially, at the pace they want to.”  In other words, story-telling behooves us all, patients and practitioners.  Like many of Koven’s insights, this resonates with me as an attorney who practices law as both counselor for physicians but also as a trial lawyer; trials are an embodiment of story-telling, and, whether in trial or mediation or an office setting, an attorney’s clients often both want and need the catharsis of telling their stories.

Speaking of medicine and literature, and by way of explanation of my hyphenated description above of the author as a “doctor-colleague-writer-teacher-mother-daughter-sibling,” as Koven explains toward the end of her book, “a dean at Harvard Medical School tells incoming students to begin thinking from the outset of their careers about what their ‘hyphen’ will be:  Physician-scientist?  Physician-educator?  Physician-advocate?”

A Shift in the Profession

Crafted by a physician, Koven’s essays contain a dosage of disease and death.  Regardless of whether one works as a healthcare professional, it is of interest to see behind-the-scenes details of the working and personal lives of physicians (hence the popularity of doctors in popular culture, especially television).

Koven points out in her essay, “Science and Kindness,” that a shift occurred over time in the medical profession, from a unified medical science and art, to a profession more overtly emphasizing science.  Koven cites a medical historian, who credits Michel Foucault as identifying, “the moment when physicians combined dissection with clinical practice as ‘the great break in the history of Western medicine.’  Instead of seeing themselves as people designed by society to attend to people who are suffering, they began to think of themselves as scientists.”  Koven is quick to point out that, for a time, the trend was for males to be seen as the “scientists” (doctors), “while compassionate care was mainly the purview of women (nurses and other non-physician medical professionals).”   Koven also takes note of the irony in, “This perceived gender split gain[ing] traction throughout the twentieth century even as more and more women became physicians.”

Also in the essay on “Science and Kindness,” Koven cites with approval the “often-quoted credo [that] has been attributed to both Hippocrates and Osler:  It is much more important to know what sort of patient has a disease than what sort of disease a patient has.” 

A Brief Bibliography of Writing and Medicine

Koven’s collection is worth reading for many reasons:  In addition to the fact that she is an excellent writer, she is funny and, of course, she is wise.  In addition to sharing her own wisdom in the pages of “Letter to a Young Female Physician,” Koven’s essays  contain a wealth of references for further reading about the medical profession and/or by physicians, a canon to which her own work now belongs.  While the collection does not contain a bibliography, it does have a “Notes on Sources,” which includes the relevant citations.

In addition to many influential essays and studies published in medical journals, as well as George Bernard Shaw’s 1906 play, “The Doctor’s Dilemma” and a number of short stories (Chekov was a physician) and poems (as was William Carlos Williams), the books Koven mentions include, but are not limited to, the following:

  • Letters to a Young Physician Just Entering Upon Practice, by James Jackson (Boston: Phillips, Samson and Company, 1855);
  • Letters to a Young Doctor, by Richard Selzer (New York: Simon & Schuster, 1982);
  • Treatment Kind and Fair: Letters to a Young Doctor, by Perri Klass (New York:  Basic Books, 2007);
  • Down From Troy:  A Doctor Comes of Age, by Richard Selzer (New York:  William Morrow & Co., Inc., 1992);
  • Illness as Metaphor, by Susan Sontag (New York: Farrar, Straus and Giroux, 1978);
  • The House of God, by Samuel Shem (New York: P.Putnam’s Sons, 1978);
  • Woman Doctor, by Florence Hazeltine, M.D. and Yvonne Yaw (Boston: Houghton Mifflin, 1976);
  • The Wisdom of Menopause: Creating Physical and Emotional Health During the Change, by Christine Northrup (New York:  Bantam Books, 2001);
  • Your Medical Mind: How to Decide What is Right for You, by  Jerome Groopman and Pamela Harzband (New York:  Penguin Books, 2011); and
  • Intoxicated by My Illness, by Anatole Broyard (New York: Ballantine Books, 1992).

Despite the fact that doctoring was in her family, Koven admits that, “I began my medical career with less than genuine passion . . . [but] in time I fell in love [with the profession].” She notes that, “Every doctor has his or her own personal origin myth, a story we tell about how and why we embarked on the profession.”  What Koven really wanted as a child, she says, was “the freedom of men” like her father, who “left the house early and didn’t return home until after dark.  He wore the pants and he made the money.  I wanted that.”  Indeed, throughout her essays, Koven highlights the struggles that women have had in the workplace, and specifically in the medical workplace.  To this day, as she points out in the title essay, “female physicians annually earn on average $20,000 less than our male counterparts . . . are less likely than men to receive academic promotions; are still underrepresented in leadership positions, even in specialties such as OB-GYN in which we are a majority, and are subject to sexual harassment ranging from unwelcome ‘bro’ humor in operating rooms and on hospital rounds to abuse so severe it causes some women to leave medicine altogether.”  Strikingly, this essay was published on May 18, 2017 and not in 1917!

It is an unfortunate reality that in medicine, as in, sadly, most fields of endeavor, women are underpaid in comparison to their male counterparts.  As an employment attorney, I have handled many sexual harassment and equal pay cases.  To this point, I have not had the honor of representing physicians in either type of case.  Nonetheless, I expect that I will be called upon to do so in the future, even though it is now 2022 and not 1922.

Koven’s mention of origin stories helped me to recall my own decision to become a lawyer.  There was not a specific moment in time, but more an accumulation of nudges, signs and assistance along the way.  Similar to Koven, I, too, was an English Literature major, attending college at Montana State University.  Without a clear direction in terms of a career – for goodness sakes, I wasn’t even in the English teaching track – I recall that in my second year of college, when I was home for spring break, my mother took me to a lawyer’s office.  My parents didn’t have much occasion to need a lawyer, but, when they did, they relied upon the services of a gentleman who had a small office on the second floor of an aged office building on Main Street in our small town in Eastern Montana.  We climbed the stairs and waited nervously in the reception area.  Then we sat across the desk from the lawyer as he talked about his work.  I recall mainly that his office was dark and, frankly, a little depressing, but the attorney was generous in sharing a bit of his experience and wisdom.

Those were different times, but in terms of the challenges that women have had in the workplace, and continue to have, I remember what the lawyer said to me, just before we left his office:  “One more thing.  I recommend marrying a woman who can type, because then she can be your secretary.”   While I wasn’t thinking of equal pay or gender discrimination claims at that point in my life, that comment strikes me, in retrospect, as evidence that the times are changing, ever so slowly.  There is a lot more work to be done in the medical profession, and in the legal profession, to see that humans of whatever gender or inclination or background have equal opportunities to share their talents, wisdom, and experience.  The writing, the publication, and, yes, even the act of  reading books like “Letter to a Young Female Physician,” are steps in that right direction.  As MLK stated, “the arc of the moral universe is long, but it bends toward justice.”

We hope it does.  Let’s see that it does.